Finding the Right Balance in Pain Relief

by
  • Agarwal, Rita, MD, FAAP, FASA
| Jul 05, 2016
Agarwal-Rita

After surgery for my broken tibia, I realized that there were only four points on the pain scale that really mattered to me:

1. I’m OK. This acetaminophen/ibuprofen/whatever is enough.
2. I wouldn’t mind a little something more, preferably something that binds mureceptors.
3. Umm, could you please hurry that up?
4. NOW!  NOW!  I need it NOW!!

leg_pain​On the 0 to 10 pain scale, who really cares if you are at a 2 or a 3, a 3 or a 4? What does that really mean? Either we want or need additional drugs, or we don’t. Either I am OK with oral opioids, or please give me something faster, stronger, and better. As a patient, I answered with whatever number I needed to say to achieve my goal—either please leave me alone, or please give me pain medication.

Good pain management is both elusive and sublime. I assumed that what I was prescribed after surgery would be all I needed. I don’t think I am a wimp – no one actually realized I had a significant injury until the X-rays revealed the crack in my tibial plateau. But I was surprised at how little oxycodone I was sent home with (about seven days’ worth), considering the nature of my injury. No opioid crisis here!

Presumably I was supposed to get a refill if I needed it? Or just white-knuckle it? The fact is that I hurt like the dickens for quite a few weeks after the surgery. There were days when I was almost in tears, and could better appreciate what drives people to want narcotics.

This experience was a marked contrast to the first time I had a fracture, when I fell off my bike onto my outstretched hand, and broke the radius and ulna. That time, I went home with a blessedly wonderful infraclavicular catheter for several days, and opioids for a few weeks.

I doubt that my tibial fracture experience is unique. I think a lot of people suffer after major injuries and surgery, and this may worsen in the future. The CDC’s new guidelines, aimed at reducing inappropriate opioid prescription for chronic pain, may swing back too far once again. People will still find other ways to self-medicate, and look to unsafe sources.

It will take everyone’s efforts to find solutions to the opioid epidemic:  the CDC, FDA, state licensing boards, and all of us as physicians, parents, and patients. We need to keep looking for opportunities to educate our colleagues regarding too much or too little, about alternatives and graded approaches to this multifaceted problem. We all hear and read of oxycodone prescriptions being written for back spasms, and about patients going home with 100 Percocet tablets after minor oral surgery. We’ve all seen surgeons prescribe a week’s worth of opioids after “ditzelectomies” so they won’t get any middle-of-the-night phone calls.

opioid

On the inpatient pediatric pain team, we struggle all the time to balance enough opioid with not too much. A recent survey from Johns Hopkins showed that while the majority of parents received and filled opioid prescriptions for their children after surgery, on average only 30 percent of these medications were administered. What happened to the rest? The majority of the parents in this survey received no instruction about safe disposal of leftover narcotics.

The opioid crisis often starts in adolescence, with children using medications left in medicine cabinets—at the homes of their parents, or their friends’ parents, or the neighbors. Who has a locked cabinet to store controlled substances? Do we know what patients do with their leftover opioids?

recent study in JAMA Internal Medicine showed alarming results about how adult patients handled their own prescribed opioids. More than 20 percent reported sharing their opioid medications with another person. Of the patients who had leftover medications, 61 percent reported keeping them for future use. Nearly half of the adults with recent opioid medication use did not recall receiving any information about safe storage or proper disposal.

Electronic prescribing may make getting refills easier, thus allowing physicians and other practitioners to err on the side of small initial doses with refills as needed. A recent opinion piece in JAMA nicelyarticulated the pros and cons of balancing excessive prescribing with effective pain management, and pointed out that the strategy of prescribing only a few days of opioids for initial use has recently become the law in Massachusetts. Some pharmacies offer “take back” days so that they can safely dispose of leftover medications. We need more and better programs like this.

Accidents happen, and any of us may end up with the joy of a broken bone, and the further fun of orthopedic surgery. I’ve been skiing for almost 30 years, and while I’ve never been a great skier, I’m not a beginner. This time, I was skiing with my family over spring break. I wasn’t doing anything stupid – I just got distracted, crossed my pole tips on a steep, icy run, and fell hard on my knee. My pain is much better now, and I’m almost off crutches.

The experience highlighted for me the personal and subjective nature of pain, and the challenges faced by patients and clinicians in achieving optimal and safe pain management. We need to keep looking for better medications, better treatments, better blocks, and longer-acting local anesthetics. We need safer ways to get rid of leftover opioids. And we need better support for patients, parents, and clinicians, so that controlling the opioid epidemic doesn’t lead to more uncontrolled pain.

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